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1、Management of LUTS due to BPH,Made possible under an educational grant from:,Case 4,Learning objectives,Discussion of this case will assist urologists to: Advise patients on the choice of -blockers, 5- reductase inhibitors, and phytotherapy Define the role of noninvasive techniques (especially TUNA)
2、,Case Presentation,Albert Scoffield, 64 y.o. engineer Hypercholesterolemia Smokes No major illnesses or operations Married, sexually active,History,Increasing LUTS for 10 years Recent increase in irritative symptoms AUA symptom score 18, bothersome score 5 Examination General examination - normal Pr
3、ostate - 75 gm, smooth, rubbery gland. No nodules,Investigations,InvestigationResult Serum PSA2.8 ng/mL UrinalysisNormal Serum creatinine85 mol/L UroflowmetryAverage maximum flow on 3 readings = 5.2 mL/sec PVRLess than 20 mL,Discussion Point # 1,The patient wants relief of his symptoms. Which therap
4、eutic agent or class of agent would you suggest?,Medical Management of LUTS due to BPH,Phytotherapy Saw palmetto, numerous herbal extracts Little long-term efficacy data Meta-analysis suggests saw palmetto better than placebo, as effective as finasteride,(Wilt T. JAMA 1998;280:1604),Medical Manageme
5、nt of LUTS due to BPH,5- reductase inhibitor (finasteride) long-term complications of BPH, may need for surgery More effective with larger prostates ( 30 to 40 gm) May prostate volume 20% to 30% Erectile dysfunction in 5%,(McConnell J. N Engl J Med 1998;338:557),Medical Management of LUTS due to BPH
6、,Alpha-blockers More effective in ing symptoms and ing uroflow than finasteride Rapid response Can cause abnormal ejaculation (up to 5%) Tamsulosin gives fewer cardiovascular side effects than terazosin or doxazosin,(Goldenberg S. Can J Urol 1998;5:551),Discussion Point # 2,The patient is worried ab
7、out sexual side effects, has heard about thermotherapy, and requests your advice. What would you say?,Transurethral Needle Ablation of the Prostate (TUNA),Produces temperature of 100 C Destroys nerves (permanent -blockade), dessicates/shrinks tissue Done under topical anesthesia As effective as TURP
8、 in ing symptoms, not as good at ing flow rate Less expensive than TURP, fewer complications Long-term data not available,Discussion Point # 3,The patient decides on a TURP, but requests laser. What are the arguments for and against laser TURP?,Laser TURP,Holmium laser produces very localized temper
9、ature of 2000 C Less bleeding than conventional TURP Shorter in-hospital stay Some centres use local anesthesia Usually shorter catheterization period, may not be necessary,Discussion Point # 4,The next day, this well-informed but unfortunate patient has a large MI, complicated by ongoing atrial fib
10、rillation, requiring warfarin therapy, and ongoing angina requiring multiple medications. In hospital, he develops urinary retention and fails two trials of voiding. What now?,A Complicated Case of BPH,Indwelling catheter used for six months, but risk of infection, bleeding, discomfort, are concerns
11、 CIC considered, but risk of bleeding because of warfarin Laser surgery could be done under local anesthesia, but pain could provoke angina Prostatic stent probably the best option,MajpjMVcyzj21HLfrvy96dv02lPPfYgxUS7IYmZkyEmZ0kGeYZS3bpLCkYH1lt4EK7CxmUX3ijoYSOer7ZuaVWYgz4EpZrUirVpMzzvNtf1XZw5oswSXOtF
12、aejnOcmfE1lZgnN1RSXg8wLCG8CVQ3XPJMvodPFWcpiYJgZazNSEPNIaklYSu7qSd1UpaxmZDlpN9zW7kljfsLCLi26Yv109ffbnDH8LbUN1G6ACURQ39eG12KHL9tXsZ1jzgoCK8g1kuNOh5eFvcmVT5ZYVQt9zk3rp3qLnf02FovEXxVRxjCcFRNppiJljNiOuk6fONnyX7fyGg7sXZ49BmCN5oy9VesHpKzdjTKwjrkCEQCFDehVmGax3lrOEbw63VscA3YSijtUKoCyiLzAlVRp7l4QgPNHxvJFFDyjU
13、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,